|
 
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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 8
| Issue : 4 | Page : 167-170 |
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Demystifying early carious lesion: A review
Ravi Gupta1, Anitha R Kumari2, Hunny Sharma3, Lipika Jain2
1 Department of Conservative Dentistry, Faculty of Dentistry, Melaka Manipal Medical College, Manipal University, Manipal, India
2 Department of Conservative Dentistry and Endodontics, V S Dental College, Bangalore, Karnataka, India
3 Public Health Dentistry, Clinician and Researcher, Smile Recovery Multispecialty Dental Care, Raipur, Chhattisgarh, India
| Date of Web Publication | 14-Dec-2017 |
Correspondence Address:
Ravi Gupta
Department of Conservative Dentistry, Faculty of Dentistry, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/srmjrds.srmjrds_59_17
Dental caries is a common disease affecting teeth present in the oral cavity. Dental caries is a disease process resulting in the dissolution of dental hard tissue like enamel and dentin. There has been a change in concept from GV Black's “extension for prevention” to a minimal intervention approach in the recent time. Accurate and reliable detection of early enamel caries is very crucial. The new diagnostic methods and remineralization approach would enable the dentist to detect and diagnose early and direct appropriate preventive measures to promote conservation of the tooth substance. These preventive strategies are much more efficient. The aim of Minimal dentistry is to manage early carious lesion by remineralization. The objective of writing this review on early carious lesion is to understand the early caries disease process and its clinical stages, identification of early caries before there is evidence of surface cavitation through various new technologies and allowing remineralization of such lesion.
Keywords: Demineralization, early carious lesion, remineralization agents, remineralization, white spot
How to cite this article:
Gupta R, Kumari AR, Sharma H, Jain L. Demystifying early carious lesion: A review. SRM J Res Dent Sci 2017;8:167-70 |
| Introduction | |  |
Enamel is most susceptible to dental caries due to bacterial accumulation and acid attack. Dental caries is a dynamic process due to disturbance between demineralization and remineralization activity.[1]
The main agents responsible are frequent ingestion of fermentable carbohydrates, reduction in salivary function, and increase acidogenic flora. It occurs when acidogenic bacteria in dental plaque – mainly Streptococcus mutans and Lactobacillus acidophilus  211; ferment carbohydrate in the diet-producing lactic acid. These acids result in the dissolution of the mineral content of tooth and initiate the carious process.[2]
Early enamel caries lesion appears as a white opaque spot and is characterized by being softer than the adjacent sound enamel.[3] The early carious lesion is a defect with a relatively intact surface layer, and subsurface changes occur due to acid which is accumulated on the tooth surface.[3] The initial stages of the carious lesion are characterized by a partial dissolution of tissue called “white spot lesions.”
Bishara et al., 2008, defined white spot lesions as the subsurface porosity of demineralized enamel that manifests itself as milky white opacities localized on smooth surfaces. This defect has a low mineral content as a result of which the surface layer is porous as compared to sound enamel.[4] Enamel demineralization is characterized by the removal of soluble magnesium and carbonate mineral content. This allows acids from plaque to penetrate the surface and attack the subsurface and leading to white spot or early carious lesion.
Early caries lesions are also known as incipient lesions and “surface-softened defect” or white spot lesion. The differentiation of early carious lesion from arrested lesions is important. “Microscars” were seen on active progressing carious lesion.[5]
The early carious lesion is known to be reversible in nature and can remineralize when treated with proper preventive and remineralization approach.[6] Early detection and diagnosis play a major role to halt the progress of the disease process.
| Clinical Characteristics of Early Carious Lesions | | |
- On drying with air using a three-way syringe, incipient lesion appears as a chalky white spot on the enamel surface. This is due to difference in refractive index of sound enamel, water, and air which is 1.62, 1.33, and 1.0, respectively. Initial demineralization during caries attack makes the enamel porous; these microporosities of surface enamel are filled with a watery medium, i.e. saliva who's refractive index is almost similar to water. However, when tooth is dried or desiccated, saliva filled in these microporosities is replaced by air who's refractive index is 1.0. This difference in refractive indices between the enamel crystals and medium inside the porosities causes scattering of light in different angles as a result affected enamel appears whitish opaque or chalky white with loss of enamel translucency when dehydrated [7],[8]
- Similarly, when rehydrated chalky white incipient lesions disappear due to replacement of air in microporosities with saliva [7],[8]
- The enamel surface is porous in nature [7]
- Active lesions are seen in plaque stagnation areas and close to the gingival margin
- The surface layer being porous is susceptible to damage by probing, especially in pits and fissures.[7]
| Sites of Occurrence of Early Carious Lesion | | |
Most common site is cervical third of a tooth, especially patients with prosthodontic restorations and patients who are undergoing orthodontic treatment.[9],[10]
| Benefits of Early Carious Lesion Detection | | |
Benefits are:
- Ability to “remineralize” noncavitated tooth surfaces [9]
- Decrease progression of the carious process
- Reduced tooth sensitivity associated with the deeper lesion [9]
- Preservation of natural esthetic and function of the tooth
- Reduced treatment cost and conservation of tooth structure.[11]
| Diagnosis and Detection of Early Carious Lesion | | |
Diagnosis of the early carious lesion is important and preventive measures can be used to control disease progress. Old methods of detecting early lesions include visual and clinical examination and radiographs. However, these methods are not accurate in the assessment of early carious lesion and may give false-negative results.
Radiographs fail to detect early carious lesion because 30%–40% mineral loss is required so that lesion can be seen radiographically. It takes a long time for demineralization to be visible on radiograph which makes diagnosis much more difficult.[12]
Old diagnostic methods are not reliable for early carious lesion detection since they lack sufficient reliability.
At present, many new diagnostic modalities have been introduced in market such as digital imaging fiber-optic transillumination, optical coherence tomography, laser fluorescence, electronic caries meter, Raman spectroscopy, and Terahertz imaging which makes the process of diagnosis of early carious lesion much more accurate and easier.[13],[14]
| Management | | |
Education and motivation of patient
It is important to educate patient regarding early carious lesion and motivation to maintain proper oral hygiene so that these lesions can be prevented.
Mechanical/chemical plaque control
Mechanical methods of caries prevention include oral hygiene procedures such as proper tooth brushing, use of floss and interdental cleaning aids, and professional oral prophylaxis.[11]
The mouthwashes containing antimicrobial agents such as chlorhexidine, triclosan, and cetylpyridinium chloride and tooth paste containing anticariogenic and remineralizing agents such as flouride and CCP-ACP.
These toothpaste are proved to be highly effective in reversing incipient caries. These strategies are highly effective in arresting and reversing early carious in lesions in high-risk people.
Remineralizing agents
These are the agents which are commonly used to manage early carious lesions or white spot lesion through a remineralization approach. They increase oral calcium and phosphate levels and shifts the equilibrium toward remineralization.
Apart from white spot lesion management, they are also used in patients undergoing orthodontic treatment and bleaching procedure to reduce decalcification risk.
| Various Remineralizing Agents | | |
Fluorides
The anticaries effect of fluorides is known since a long time. It increases the resistance of enamel to caries by increasing rate of enamel maturation and alteration in tooth morphology. Moreover, it also inhibits enzyme enolase and thus enhances remineralization.[15]
Casein phosphopeptide-amorphous calcium phosphate
It is discovered and patented by Eric Reynolds and coworkers at the University of Melbourne in 2002. It is protein nanotechnology which involves the use of specific phosphoproteins from bovine milk and combines it with nanoparticles of ACP.
It acts by localizing ACP at the tooth surface, which buffers the free calcium and phosphate ions and forms a supersaturated solution of these ions enhancing remineralization.[16] GC Tooth Mousse is used in cases of enamel lesions and white spot lesions.
Tricalcium phosphate (Clinpro Tooth creme)
During brushing when TCP paste comes in contact with saliva, it causes the release of Ca, P, and F ions and thus brings about the process of mineralization.[17]
Novamin
It is based on bioactive glass technology. On contact with saliva, it rapidly releases sodium ions which raise the local Ph and causes the release of Ca and P.[18],[19]
Enamelon
Based on the ACP technology, in which ACP was incorporated into toothpaste to bring about the process of remineralization.[20]
Xylitol
It is a sugar substitute which shows anticariogenic as well as cariostatic action. It inhibits the growth of S. mutans. Xylitol also stimulates increases salivary flow which reduce the risk of caries and promote remineralization.[21],[22]
Sensistat technology
Based on arginine technology, in which arginine bicarbonate, amino acid, and calcium carbonate particle are incorporated in toothpaste. This arginine compound holds calcium carbonate particles on the tooth surface as a result of which calcium carbonate dissolves slowly and release calcium which results in tooth remineralization.[23]
Grape seed extract
Enzyme glucosyltransferases are inhibited by Proanthocyanidin (PA) present in grape seed extract which in turn inhibits caries. Grape seed extract is a promising agent in future, but further studies are required to establish its role.[24]
Nano-hydroxyapatite
Recent studies have shown that a concentration of 10% nanohydroxyapatite crystals can result in remineralization and can be used for the management of early carious lesion in the future.[25]
| Resin Infiltration Method | | |
It is a new method which involves infiltration of resin into the porous enamel of early carious lesions, thereby preventing the disease progression.[26] It is a noninvasive method which is safe and simple. Marketed as ICON caries infiltrant. Hence this new method is beneficial in management of various problems like white spot lesions, amelogensisis imperfecta, and molar incisor hypomineralization.
Belli et al. concluded that this method improves surface stability and reduces the risk of early carious lesion.[27]
| Conclusion | | |
The dentist should diagnose and treat noncavitated early carious lesions with the help of new diagnostic methods with an emphasis on remineralization and prevention rather than restoration.
The current change in the approach to dental caries and the popularity of minimally invasive dentistry and preventive dentistry have resulted in an increased demand for materials to remineralize the tooth structure.
These agents are an adjunct to preventive dentistry and research is going on to find a suitable remineralizing agent that can result in complete reversal of the carious process and complete remineralization of the enamel and dentin.
There are no conflicts of interest.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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